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Stab of Coliforeia—Environmental Protection Agency <br />Form Approved OMB No. 2050-0039 (Expires 9-30.99) See Instructions on back Of r le 6• Department of TOFK Substances Control <br />Please-printurtype. Form designed for use on slim (12-pinch) M. Sacramento, California <br />UNIFORM HAZARDOUS. <br />I. Generator's US EPA ID No. Manifest Document No. <br />2. Page 1 <br />Information in the shaded areas <br />a not required by Federal law. <br />WASTE MANIFEST <br />0 <br />1 <br />1 ry <br />o11 <br />3. Generstar's Name and Mailing Addressus, Wotnbe <br />- iak i t r <br />k. wt .c <br />O—PILE 98891 <br />0 <br />s 10 N. CLUFF AVE. , LODI, - CA 95240 : Stem G nter's <br />n <br />A. Generator's Phone 209 1369-4751 <br />N <br />h <br />5. Transporter 1 Company Nam. 6. US EPA ID Number ' .State Transp.,ex's ID " <br />OF <br />OR GAL OIL <br />Traesparter's Phone <br />O <br />7. Transporter 2 Compan Nama <br />p y 8. US EPA ID Number ",Slate Transporters ID <br />si• <br />QTransporter', <br />Phone <br />U <br />�-ceZ <br />9. Designated Fociliy Nama and Sib Address 10. US EPA ID Number G. Stare F i ity's ID <br />`� <br />NDUSTRIAL VP,VIC-E OIL CO, n'' 7 <br />17PI <br />o <br />DO <br />"00 S. 5O O T. : FadGy;P �°gg r <br />ANGELES. � �% 15 � <br />j <br />_OS CA. 9Ci023 A <br />:)v C.' <br />Q <br />"U <br />11. US DOT Descri on (Including Proper r Shi Name, Hazard Class, and ID Number <br />Ptl (' 9 PM Shipping 1 <br />12. Containers <br />No. <br />T <br />13. Total <br />Quantity <br />14. Unit r <br />Wt/Vol 1. Waste Number - <br />�iZ <br />a. <br />,p� <br />ON—RCRA HAZARDOU5 WASTE LIQUID <br />State <br />tt., <br />jy3 <br />t <br />{WATER & SLUDGE? <br />010f <br />T T <br />0161 <br />G E'A'Oher <br />o <br />E <br />N <br />b. <br />Sate <br />w°° <br />E <br />v <br />R <br />m <br />O <br />_. <br />— <br />It <br />oc <br />w <br />d. <br />S <br />Z <br />W <br />U <br />EP <br />su <br />Z <br />J. Additional Descriptions for Materials Listed Ab <br />'•5'.. <br />ing Cedes ter Wastes Listed Above, <br />TANF. BOTTOM WASTE <br />C. I <br />P.IN9ATE <br />cd. <br />0 <br />15. Special Handling Instructions and Additional Information -- <br />a <br />!'PP,OPRIATE PROTECTIVE CLOTHING <br />Z <br />*EMERGENCY CUNTACTg{209)541-9145" <br />F <br />3EE E.R.G. 171 <br />QIL-GENERATOR'S <br />CERTIFICATION: I hereby declare Real elle contents of Ilii, consignment an Fully acrd accurahlr, described above by proper ship ing name and are classified; pocked, <br />marked, and labeled, and are in all respects in proper condition far transport by highway according to applicable inhmational and radiates government regulations. <br />U <br />J <br />Npracticohis <br />IF I am a large quantity generator, I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined ro be economically <br />and that IT. selected the i able method of treatment, storage, or disposal currently ayo8nbfs to me whi-h the future threat to human health <br />minimus present and <br />and the environmem; OR, if I am a small q�antiy generator, I have made a good faint effort to minimize my waste generation and select the best waste management method that is <br />O <br />available to me and that I can afford.--- <br />} <br />Printed Nam <br />signature <br />Morns Day Year <br />Z <br />L Qin f l'e� <br />z' X'7 , <br />1 <br />w <br />I <br />R <br />17. Transporter 1 Acknowhschgssxnventof R i f of Materials <br />sty <br />N <br />Pdnbd/Typed Name / 7v-si <br />Rectum i f <br />nth � Day... Year -• <br />2`�C.,.� <br />O <br />P <br />B <br />18. Trans now <br />Transporter 2 Ackled menti of Receipt of Materials <br />TPrinted/Typed <br />j <br />Name '- s %Y <br />/i ay.... <br />5gnaare <br />Month Day Year <br />R <br />r/ -.7 f; e <br />V19. <br />Discrepancy Indication Space <br />Z <br />— <br />F <br />q <br />C <br />I <br />L <br />� � <br />( <br />20. Facili er orator Cs 'fic of t ardous materials <br />covered by this st sl is red in Ill <br />T <br />Prinbd/Typ - <br />Signature / <br />yearY <br />/ d <br />DO NOT WRI E BEL HIS LINE. <br />DTSC 8022A (4/971 - <br />EPA 8700-22 - -- - --F aen. TRANSPORTER RETARDS _ <br />